Health policy

It’s a pleasure to be here at Queen Margaret University – an institution whose school of health sciences has developed a strong and well deserved international reputation for teaching and research. The 3,000 people who are studying at the school today will, I have no doubt, go on to make a major contribution to the health and wellbeing of people here in Scotland and much further afield.

So this is an ideal venue to speak about the future of health and care services in Scotland.

There is no doubt in my mind that this - the second decade of the 21st century - is a pivotal moment for health care and healthcare systems, not just in Scotland but around the world.

An ageing population, a shift to more multidisciplinary working and rapid advances in research and technology - to cite just some of the trends we see - present challenges and opportunities that the founders of the NHS could scarcely have imagined.

It is the decisions we take today - on research, on the organisation of our NHS, on the relationship between and investments in social, community, primary and secondary care, and on the education and training of the health and social care workforce of the future - that will determine how well our health service responds to these challenges and opportunities.

As First Minister, and I also speak on behalf of the Health Secretary,’ I am determined that we take the decisions - including the tough decisions - that will ensure that our health and care services are fit for the future.

Indeed, today is one of a series of Scottish Government events focussed on the future of health and care services

On Monday I visited the Stratified Medicine Centre at the new Queen Elizabeth University Hospital in Glasgow. That centre assesses data to find out how people with different genetic make-ups will respond to different treatments. It’s a good example of how new technology is transforming our ability to treat patients.

The purpose of my visit was to announce £4 million of funding to support research into precision medicine – medicine which is specifically tailored to meet the specific needs and characteristics of individual patients. Precision medicine is a field which has the potential to transform health care in the years ahead. It will bring huge benefits for individuals and for the health service alike – it can reduce the risk of wasteful and ineffective prescriptions that do little to help some patients, and provide better and more effective personalised treatment to patients, tailored to their genetic make-up and the particular characteristics of their disease.

And Scotland - due in part to our size, the strength of the collaborations between our NHS, our universities and industry, the skills of our clinicians, and the wealth of comprehensive, joined up patient data that we have access to - is now ideally placed to be, not just a world leader, but perhaps the world leader in the development and commercialisation of precision medicine.

The funding I announced on Monday will help build the infrastructure - the precision medicine ecosystem - that we need to seize that opportunity.

It is not the largest health investment I have ever announced - far from it - but it could be one of the most significant.

Next week we will also be launching our new National Clinical Strategy –which will set out how we will deliver a health and care service which meets people’s needs in the years and decades ahead.

All of this is happening at the time of our national conversation on a healthier Scotland. The Scottish Government has heard from more than 7,000 people at over 150 events across the country – and thousands more online - on how we can build a healthier, happier and fairer country.

So today is an appropriate time to reflect more broadly on the health service in Scotland - on what’s been achieved in recent years, and how much more we need to do in the years ahead.

And in my remarks, for all the complexity involved in delivering modern health and care services, the basic argument I’m going to make is actually a very simple one. It’s this - care should always be delivered as locally as possible. In fact, when possible, it should be delivered at home. That’s not a new idea, but it is even more important now than it has been in previous decades. As more people live for longer, we need to support them to live as independently and healthily as possible.

And so I want to talk about some of the fundamental changes and reforms that we’re making to health and care services which will help us to achieve that aim.

To do that, I’m going to look in some detail at the integration of health and care services; the transformation of primary care; and the provision of specialist operations. And at the end of my speech I’m going to talk about the health and care workforce without whom we can’t do anything we’re talking aobut today and which I hope that some of you in this audience will soon be joining – and announce some further and hugely important investments there.

First, let’s talk about the challenges. Now, the population change that we’ll face in Scotland in the coming decades is already easy to predict. At the moment there are around 430,000 people in Scotland aged 75 or over. By 2039, when I’ll be a lot older and you’ll all still be very young, that number will increase by 370,000 – that’s roughly the same as the population of Aberdeen and Dundee put together.

That trend is of course a hugely welcome one and we shouldn’t see it as a burden or a challenge- it means more of us are living longer into old age. But it has two very significant implications for our health and care services.

The first is that although the increase in average life expectancy is something we should celebrate, we cannot ignore the massive inequalities which exist between different parts of Scotland. Those inequalities are a scar on our society. Here in south Musselburgh, for example average male life expectancy is 76. Just 4 miles away, in Niddrie, it is 58. Fundamentally, that's not an issue which can be fixed by health services alone – it’s a consequence of deep-seated inequalities in our society. It emphasises the importance of our wider work to tackle poverty, deliver quality affordable housing and improve support for parents when children are in their early years.

And it also demonstrates that prevention of illness - promoting healthy lifestyles and encouraging wellbeing - has to be at the heart of what we do. Whether we’re making it easier for people to be active, or encouraging them to stop smoking, or tackling the harmful consumption of alcohol, a focus on prevention must continue to be central to everything that we do. It’s essential to tackling health inequalities, and it is also the best way of helping everyone to live as healthily as possible for as long as possible. And we don’t just want people to live longer, we also want them to live good, healthy lives.

The second point about demographic change is straightforward. As more people live longer, it will have a direct impact on where and how we deliver health and care services.

The NHS in Scotland today is a world-class service delivering world-class care. Just two weeks ago, for example, a report from the Royal College of Emergency Medicine described UK accident and emergency services as the best in the world, and Scottish services as the best in the UK. That’s an incredible tribute to the people who work in those services.

And its reflected in public opinion. Public satisfaction across NHS Scotland services is at a historically high record. Satisfaction with GP services has also increased.

But it’s the very nature of health and care services that we can always do better – sometimes significantly better. We have to adopt new medicines and new technology; we have to adapt to a changing population, and we have to meet ever-higher public expectations.

That’s why this April will see the most important reform to healthcare in Scotland since the foundation of the NHS in 1948.

The integration of health and care services is something which many of you will know about as students or professionals – but the reasons behind it can be easily understood by almost everyone in Scotland through personal experience and through knowledge of family, friends, colleagues and neighbours.

An increasing number of people have one or more chronic conditions, which need long-term management but - if they get the right care - they will only occasionally require a visit to hospital. They are perfectly capable of living independently at home, but they need a little bit more support, sometimes a lot more support, in order to do so.

It’s important for them that the care worker who visits them several times a week is in touch with their GP and community nurse, with the pharmacist who handles their prescription, or maybe the befriending service they use once a week. And it’s vital that if they need to go to hospital – if they have a fall, say, or need a minor operation – that their hospital treatment is co-ordinated with their care arrangements. That means that they’re able to return home as soon as they are well enough to do so, rather than remaining in hospital for longer than necessary. Because all of you, in training, will be aware of the evidence that the longer older people stay in hospital, then the more likely they are to lose their independence.

That’s why the integration of health and care is so significant. It’s a change which recognises the reality of people's everyday experience - it ends once and for all the arbitrary distinction between health and social care and instead focuses on the holistic needs of the person.

Of course, integration by itself doesn’t guarantee better care – but it does mean that different services are much more able and likely to work together effectively.

We're already seeing encouraging progress in some areas.

For example delayed discharge has been a major priority for us – that's when people can’t leave hospital because care and support arrangements aren’t in place for them at home. It’s bad for the patients, and it’s expensive and wasteful for the health service as a whole. In the current financial year we have seen an 8% reduction in delayed discharge rates. We still have a long way to go but we have started to make progress.

But we know that we need to do much more to ensure that integration is a success. That’s why we’re supporting integration with a transfer of £250 million in the financial year that’s about to start from the NHS to health and social care partnerships. £125 million will help to expand capacity and reduce social care charges. And a further £125 million will help to meet existing cost pressures faced by local authorities.

One important pressure we’re helping to fund is paying the living wage to care workers – something we’re determined to implement by October. Now, paying the living wage is the right thing to do anyway – for any group of workers, in any sector. But the principles at stake in the care sector are perhaps especially important. After all, carers are essential to the quality of life, the dignity, and the independence of hundreds of thousands of people. Paying the living wage is just one way– but a very important way – of demonstrating that we value their expertise, compassion and commitment.

And of course, as we move towards integration – towards providing more support for people to live at home, or in a homely environment - the importance of primary care increases even more.

We already know that the next decade will present challenges in recruiting GPs - many are due to retire, and an increasing proportion will choose to work part-time which is one of the consequences of the very welcome trend of more women going into medicine. So we are taking action. We have increased the number of GP training places from 300 a year to 400. And we're encouraging former GPs who have left to care for children or elderly relatives to return to practice.

Perhaps even more importantly, though, we are helping GPs to work more closely in multi-disciplinary teams with pharmacists, community nurses, social workers, physiotherapists, chiropodists and other allied healthcare professionals. In some cases, that's about co-location - developing a health centre within a community that have all these professionals. But more frequently it’s about changing the culture of primary care to help people to work together.

Last year the Health Secretary allocated £60 million to support this change of culture and practice. £20 million of that money is supporting the development of new approaches to care.

For example in Inverclyde, all general practices and primary care health professionals are looking at how they can share their resources and their expertise to deliver a better service for their community.

One thing they are looking at is how pharmacists can better support GPs and patients. That’s something which could allow GPs to focus more on the care of people with particularly complex needs.

They are also exploring improving how services such as physiotherapy are made available to patients more routinely.

The Inverclyde project, one of many we’ll see develop across the country, potentially improves primary care services for 80,000 people. As we move towards the new GP contract in 2017, we hope that it will provide lessons we can apply across the whole of Scotland. It’s an example of our determination to transform primary care so that patients get the best possible care at the right time. The better the care in community services, the less likely it becomes that patients will be admitted into hospital.

The importance of local care also extends to key hospital services. Now, for some procedures, quick, efficient and safe treatment requires specialised regional or national centres. Often that will be because of the highly specialised nature of the treatment in question - indeed, we've already moved to having regional cancer centres.

But sometimes, the case for having specialist centres will derive from the sheer volume of procedures required.

Many operations – such as cataract removals or knee and hip replacements – make a huge difference to people’s quality of life, even although they don’t address life-threatening conditions. And, as the population ages, the demand for these procedures will grow and grow.

So, for these elective procedures – which don’t arise as a result of emergencies, and which can be scheduled a bit in advance – it makes sense to have dedicated facilities. It means that a patient's hip replacement is less likely to be cancelled because an emergency takes priority.

The Golden Jubilee hospital in Clydebank is the shining example of this approach. It has been an outstanding success, carrying out 20,000 procedures a year, including hip replacements, cataract removals and knee replacements.

By doing that, it provides a service which makes a massive difference to the quality of life of many older people. And because scheduled services are being provided in a separate facility from emergency treatments, people aren’t subject to delays when unscheduled operations are urgently needed. As a result, the Golden Jubilee has directly contributed to the situation we see now in Scotland, where for almost all types of elective treatment, waiting times in Scotland are shorter than anywhere else in the UK.

That’s why we have already committed to invest £200 million in 5 new diagnostic and treatment centres around Scotland. We want to build on the success of the Golden Jubilee for elective procedures.

A key point is that for some procedures, specialist centres aren’t just quicker – they’re also likely to be safer. For example, evidence from the USA suggests that surgeons doing hip replacement operations should perform at least 35 operations a year. That’s easier to achieve in dedicated specialist facilities.

That emphasis on expertise and quality is why we’ll continue to plan treatment for other conditions - such as vascular disease and cancer - on a regional or national basis. It’s also why we improved the treatment of acute heart attacks a few years ago when we concentrated treatment in a smaller number of more specialised centres. For some complex procedures, that’s the best way to provide better and safer care.

But although patients need to have surgery and complex treatment in special centres, they usually don’t need to have their follow- up care in those facilities, which brings us right back to the importance of primary care. The majority of the support they require can be delivered more locally. That’s why we are planning for specialist services to be delivered by networks of hospitals. People will spend time in a major centre of expertise for those procedures where it's essential to get the best treatment, but the subsequent support they get will be in their local hospital, or at their GP surgery, or perhaps through rehabilitation services, home visitors or telehealth services. The best healthcare for the future, which we are trying to achieve through these changes, will combine specialist expertise with local accessibility.

And of course as we work towards this vision – of health and care services working together, and of as much care as possible being delivered locally, with specialist services where we need them – we need to value and support our health and care workers more than ever before. And we need to make sure that we are training the right numbers of professionals - in and across different specialities - with the skills they need for the health service of the future.

We’ve already invested heavily in the health and care workforce in the last 9 years. For example the NHS Scotland workforce has increased by more than 10,000 since 2007.

I’ve already mentioned a couple of additional steps that we are taking – funding more GP training places, and paying the living wage to care workers.

Today, I am making some additional commitments.

Our approach to student support – alongside our commitment to free tuition fees – contrasts completely with the recent actions of the UK Government. The UK Government has decided to remove free nursing tuition and bursaries. The Scottish Government is completely committed to retaining a nursing and midwifery bursary. We recognise the demands on those students, and we understand the importance of their role. So to make sure that we are well placed to attract the best young people - from all backgrounds - into the workforce, I am making a clear commitment today that we will retain free tuition and a nursing and midwifery bursary in Scotland.

Three days ago we also launched a major campaign to encourage junior doctors to come and train in Scotland. That campaign stresses the quality of the opportunities available here, but it also emphasises the value people in Scotland attach to their role and their work. On the day that doctors are on strike across England, this shows the huge value Scotland places on its junior doctors.

But it's very clear that if we're going to recruit the best possible workforce for the health and care service, we need to recruit from the widest possible talent pool.

At present only 1 in 20 new doctors come from the most disadvantaged areas of our country; if we had truly equal access to the medical profession, that figure would be 1 in 5. That’s not a reflection on the talent or aptitude of students from disadvantaged areas, it's an indication of how disadvantage acts as a barrier to equal opportunity. That’s bad for those individuals who are denied a fair chance to enter a good career. And it's also bad for society as a whole - we lose out on too many of the talented and dedicated medics of the future.

That's why we are confirming a number of measures to widen access to medical schools. For example, we will make a new entry level programme available to help secondary school students from deprived backgrounds prepare more effectively for undergraduate medical education.

We are also increasing the number of medical student places by 50 from this August. The importance of widening access to medical degrees will be a key priority as those extra places are being filled.

Finally, we will launch Scotland’s first graduate entry programme for medical students. That programme will include an offer to pay fees, which would be conditional on students agreeing to enter the NHS Scotland workforce when they qualify. It’s a further way of ensuring that financial concerns don’t deter talented graduates from studying and working in medicine - but also that we retain our best talent to work here in Scotland.

The other announcement I want to make relates to the nursing profession. I spoke earlier about the importance of reforming primary care - of ensuring that carers, GPs nurses, pharmacists, allied health professionals and the voluntary sector all work together. Multidisciplinary working - long talked about - must become a reality like never before in the health and social care service of tomorrow.

Nurses have an absolutely crucial part to play in this. That’s why we have already provided funding for additional health visitors. We’re now looking at other nursing roles. For example we want community nurses to be senior decision makers within healthcare teams. Nurses are well placed to lead care for those with complex needs – such as the frail elderly, or those needing end of life care. By doing that, they can help people to live as independently as possible and they can prevent unplanned admissions to hospital.

Advanced nurse practitioners are also hugely important. They already work closely with GPs, district nurses and other healthcare professionals. They potentially have an even bigger role to play in assessing, treating and diagnosing people in the community - during the day and out of hours. By doing so, they can help to provide better primary care for individuals and tackle delayed discharge rates.

That's why I can confirm today that we will fund the training of a further 500 advanced nurse practitioners. The nursing profession in Scotland has a long and proud tradition – one which is rooted in enduring values of care, compassion and professionalism. By investing in training, we can ensure that nurses continue to play a hugely important role, but an even more important role in the future– applying those enduring values in the health and care service of the future. These are initiatives we’re taking to ensure our health service is fit not only for today, but for the future.

This year sees the 70th anniversary of the introduction of the legislation which created NHS Scotland. The first people to be born under NHS care are now in their late 60s. My hope in the years and decades ahead, is that as that generation enters their 70s and then their 80s, 90s and beyond, they will again benefit from transformational change in Scotland’s healthcare system – that the integration of care and health services will help them to live as independently, healthily and happily as possible.

And equally, that the decisions we take today, will ensure that babies born today will be celebrating our National Health and Social Care services when they are in their 60s, 70s, 80s, 90s and, definitely by that time, their 100s!

My belief is that the reforms we are implementing across our health and care services will benefit everyone in Scotland. They will build on the success of our current healthcare system, and for all the challenges our NHS is a success, and ensure that services are delivered as locally as possible and in a way which meets people’s needs - as individuals. We need personalised care to match the personalised medicine that I spoke about earlier. If we succeed, we will reduce inequality and we will improve health and wellbeing, and the experience of healthcare, for everyone.

Many of you in this room – as you go on to take up careers in different branches of healthcare - will be central to achieving our vision for health and care services in the years ahead.

My commitment to you is that this Government will continue to value the compassion, commitment and professionalism which are demonstrated on a daily basis by health and care workers. And as today’s announcements demonstrate, we will continue to invest to help you to do your job to the best of your ability. Because we know that by doing that, we can create the health and care services that people across Scotland deserve and need. And we can make important progress towards becoming a healthier, happier and fairer nation.